| Policy Studies and Applied Research | ||||||
| General Publications and Research Topics | The Occasional Long Term Care Policy Paper Series | |||||
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Long Term Care Advances AROUND THE TABLE IN CLEVELAND COUNTY, NC: COLLABORATION AND COOPERATION AT WORK FOR THE ELDERLY From the Editors
A community's ability to identify needs and to implement solutions is fundamental to its success. This paper describes how service providers to the elderly in rural Cleveland county in western North Carolina came together to provide needed services, to fill gaps in service areas and to work together to accomplish these tasks. These service providers came to and stayed around the table to achieve the common goals agreed upon by the community. Coming Around the Table In 1987 three individual service providers began meeting over coffee to discuss the fragmented service system for care of the elderly and disabled that existed in their community. From this initial group of three, other service providers were invited to join the conversation and in March 1989 the first initial meeting of ACCES (Acessing Cleveland County Elder Services) was held. More than ten organizations attended the first meeting. Discussions centered around creating a better system of care by increasing the amount of services to the elderly, by filling gaps in service provision, and by finding ways to communicate better with each other to lessen duplication as well as share information.
Assessing Need from a Community Perspective During the time period ACCES was initiated, the United Way of Cleveland County was conducting a community needs assessment. One of the findings of this assessment was that residents of the community did not know how to access the services that were available. Focus groups also verified that information. Given the fact that few consumers knew how to find out about services, one of the goals of ACCES was to arrange for educational workshops, geared toward the community. (See Exhibit 1 for a description of the educational forums sponsored by ACCES.) In June 1990, the North Carolina Division of Aging awarded a planning grant to Cleveland County (one of four in the state to be awarded). The purpose of this grant was to survey in-home needs, housing conditions and access services in the community. The Council on Aging was designated as the lead agency for this grant and a steering committee was formed. Membership on this advisory committee were the ACCESS members, which included staff from key agencies serving the elderly, older adult consumers, members from the faith community, and county commissioners. In addition to working on the elderly plan, ACCES also began to work on a brochure highlighting all ACCES providers and on the development of the Community Alternative Program for Disabled Adults (CAP/DA) in Cleveland County. (CAP/DA is North Carolina's Medicaid Home and Community-based waiver and is an optional service at the county level.) A Course of Action Emerges In August 1991, "A Plan for Growing Older" was submitted to and approved by the Board of County Commissioners. The plan identified three strategic areas: aging well, housing, and caregiving. The work that went into this plan was done by members of ACCES, all of whom were active participants in this process. Keeping everyone involved was a key ingredient in the success of this community achieving its goals. Membership in ACCES continued to grow to include more consumers, representation from minority populations, and younger adults. Starting to Work To begin operationalizing the goals of "A Plan for Growing Older," the Council on Aging applied for a HUD grant for more housing. To address the concept of "aging well," many quality of life issues were identified. The need for home repairs and handyman chores was mentioned often. Students from Gardner-Webb University volunteered to provide these services in return for credit in their social science class. This is an example of collaboration, since Gardner-Webb was represented on the ACCES committee. ACCES also published and distributed its first resource booklet
which described services for the elderly in Cleveland County. This
booklet met one of the "aging well" goals of sharing information
and keeping members and the community informed about services for
the elderly. Hospice of Cleveland County asked ACCES for its support
of a six-bed facility that Hospice was developing. This request
for support was further evidence that collaboration and cooperation
was a reality. (See Exhibit 2 for more examples of housing options
that were built as a result of this collaborative work.)
VISIT THE DUKE LTC WEBSITE AT: http://ltc.duke.edu Funding for Service Expansion Funding was sought by ACCES for the establishment of a care management service in Cleveland County. The Kate B. Reynolds Charitable Trust awarded a two year demonstration grant to establish a care management service. Care management in Cleveland County was defined by the ACCES committee as "a service which helps provide ACCESs and coordination to care solutions for older and disabled individuals and/or their caregivers through professional screening, assessment, development of a plan of care, monitoring, reassessment and plans for discharge. Care management should be accessible through a single point of entry." ACCES designated the LIVE (Living Independently though Volunteers for the Elderly) agency as the community agency to receive the Kate B. Reynolds funds. This agency was selected in part because its governing structure met the requirements of the Foundation.. LIVE was a volunteer-based organization, but its board agreed to take on the challenge of developing a care management service for the community. In 1994, ACCES membership continued to increase with the addition of membership from long term care institutions, the Foster Grandparent program, and home health agencies. Establishing a Pharmacy Assistance Service &
During 1995, the issue of prescription drug costs for low-income elderly became a concern for many service providers and their clients. With cooperation in gathering information and collaboration in finding resources, the community established the Cleveland Pharmacy Assistance Program in July 1996. This was under the auspices of the Cleveland County Health Department. Another milestone in 1996 was the invitation that ACCES received
to become a Teaching Community, a program of the Duke Long-Term
Care Resources Program. The Teaching Communities Program goals
are "to leverage the experience of some of North Carolina's
leading communities in long term care infrastructure development
and disseminate their lessons learned to a wider audience across
the State. A forum was held in October 1996 to present the services
for older adults in Cleveland county to attendees from all parts
of North Carolina. This program highlighted the work of key agencies
in Cleveland County. Continued Collaboration The two-year grant from the Kate B. Reynolds Charitable Trust ended in 1997. Broad-based care management services as a viable, independent entity was not yet a reality in Cleveland County. The ACCES committee continued to meet and to strategize about ways to secure funding to implement the service. Acute health care providers in the community formed an "Alliance for Health" to link health care providers from both the for-profit and non-profit service agencies in the community during this same period of time. The original members of the Alliance for Health were the Cleveland County Health Department, Cleveland Center, Cleveland Regional Medical Center, and Cleveland Home Health Agency. Since many of these members of the Alliance for
Health were also members of the ACCES committee, discussions soon
focused on funding of the care management service. Budget
for the first full year of service (1999-2000) was estimated at
$147,700. The Alliance for Health received $25,000 from the County
Commissioners in 1998 to assist in developing a care management
program. Most of the remainder of the needed funds came from North
Carolina's Home and Community Care Block grant (HCCBG) allocation
to Cleveland County. Service providers gave up a percentage
of their allocations from HCCBG to assure that the care management
service would have funding for at least a year. In-kind contributions
of $60,160 from various agencies completed the needed revenue. Implementation of Care Management Services In 1999, a centralized care management service for older adults in Cleveland County was established under the name "Care Solutions." In April of 1999 the first two employees, a nurse/care manager and an administrative assistant, were hired for the care management program Cleveland Regional Medical Center donated office space, equipment, office furniture, and agreed to serve as the employer of these staff members. A management contract was signed between ACCES and the hospital, with ACCES committee members providing the operational oversight of this service. Since October 1999, 216 information calls have been
received by Care Solutions; 305 referrals have been made to other
agencies or services; and 47 clients have been provided case management
services. Currently there are 20 active case management clients. Increasing Capacity by Adding CAP/DA Services In January 2001, the CAP/DA (Medicaid Home and Commmunity-Based Care waiver) program in Cleveland County was transferred from the Department of Social Services to Care Solutions. Cleveland County has 62 active CAP/DA clients and more than 150 on the waiting list. Additional social workers and nurses will be hired to provide care management services to new active clients as they are added to the program. What's Next for ACCES The ACCES committee continues to meet quarterly, with membership active and diverse. Educational forums will continue; in 2001 ACCES will sponsor one on long term care insurance. An automated centralized Information and Referral system for the region is being discussed. As Diane Padgett, Director of the Isothermal Area Agency on Aging states: "ACCES is a success story in how agencies and organization can come together to develop a strong system of support." Acknowledgments: The authors would like to thank all the participants in this collaborative process. The people mentioned below have been particularly helpful in bringing changes to the long term care system in Cleveland County. Libbie Shipley, Director of the Council on Aging/Senior Center; Nancy Abasiekong, Home Extension agent; Diane Padgett, Director of the Isothermal AAA; Dottie Leatherwood, vice-president of Cleveland County Regional Medical Center; and Sarah Wray, retired Director of LIVE, deserve special recognition for their tireless commitment to this process. More about the Teaching Communities Program In 1996, building on the success of the Aging at Home Program, the Duke Long Term Care Resources Program launched the Teaching Communities Program with support from the Kate B. Reynolds Charitable Trust. The concept of the Teaching Communities Program was to work with communities in North Carolina where effective leadership had taken long term care systems development beyond planning into implementation. In the broadest sense, all communities were thought of both teaching and learning communities and communities in most of North Carolina's 100 counties were eventually touched by Teaching Communities events and publications. Initially, three Teaching Communities were named to begin the sharing among communities. In exchange for sharing their experiences with other communities, these initial Teaching Communities were offered technical assistance and educational opportunities to complement their continued development. Those communities were Alamance County, Cleveland County and a consortium of 5 eastern counties, referred to as the Down-East site, coordinated by the Mid-East Area Agency on Aging. Inaugural events held in each community were widely attended by community leadership along with long term care leadership from across the state. Those three communities shared many common elements and goals but also developed special interest areas that they pursued. Alamance County focused on access services and became expert on screening as a tool for information and referral and case assistance services. Staff leadership from Alamance became "master trainers" on screening techniques for a series of workshops held around the state. Cleveland County further developed expertise in volunteer programs to assist the frail and worked toward a goal of a viable, independent source of case management for older adults. The Down-East Community had special expertise in housing development and took on the issue of what communities could do to address frontline workforce shortages in long term care. From these experiences, several publications emerged which provide more detail about their work: "The Alamance County Experience: Foundations
of a Teaching and Learning Community." B. Porter, K. Berry
and H. Brennan. Long Term Advances Vol. 7, No. 4, Fall 1996 Additional Papers in the Occasional Long Term Care Policy Paper Series developed as resources to communities addressing long term care issues include: "Developing Access Services in Mecklenburg
County, North Carolina: The Just1Call Experience." B. Patnaik
and A. Geltman. Paper #12, February 2001. Copies of the above papers maybe found on the Duke LTC Website at: http://ltc.duke.edu
Long Term Care Resources Program, DUMC 2920,
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